Promoting health without promoting stigma?

Cancer Research UK (CRUK) is again under fire for its campaigning on obesity.  There was a lot wrong with their most recent posters, which equated obesity with smoking as a cause of cancer.  The debates that followed highlighted the vital role social research has to play in informing campaigns that educate and advocate for health, without inadvertently increasing health harm from stigma.

CRUK’s new posters featured cigarette packets bearing the message “obesity is a cause of cancer too”.  A group of scientists, activists and clinicians wrote an open letter that garnered thousands of signatures asking the charity to think again about the damaging effects of linking obesity with smoking as a risk for cancer.  The campaign was accused of underplaying epidemiological uncertainties over whether being overweight really does cause cancer, rather than simply being associated with higher risk.  Critics also flagged a rather worrying conflict of interest from CRUK’s partnership with Slimming World, a commercial organisation whose profits are derived from weight loss programmes which have little robust evidence for effectiveness.  As a previous Cost of Living blog argued, there are real dangers of the often-hidden corporate influences on public health programmes.

In defence, CRUK pointed to the need to raise awareness of the rise in obesity, the well-established links between bodyweight and many cancer risks, and the potential for policy change to improve the public health.  Just as regulation of the tobacco industry and smoking in public places has had a role in reducing tobacco use, the argument is that pressure to regulate food industries will be needed to address the ‘obesity epidemic’.    However, as critics of the campaign noted, CRUK’s imagery equated a ‘behaviour’ that could in theory be stopped (smoking) with a characteristic (weight) that is normally distributed across the population.

More importantly, critics argued that the campaign perpetuated a harmful discourse that obesity was a matter of ‘choice’ and an individual behaviour, and the campaign therefore risked increasing the stigma of being overweight. Decades of research has shown the huge damage that arises from weight-based stigma: these posters risked escalating the kind of fat shaming that already threatens the health of people who are overweight. Others pointed to the dubious ethical position implied (if not meant) by this critique: that somehow stigmatising smoking would be less problematic.  In the UK, those who smoke and those who are overweight are both more likely to be among the most economically disadvantaged in the population.  As sociologists Link and Phelan have argued, stigma arises not from any inherent moral or health-damaging characteristics of the person stigmatised, but from relations of power.  Stigmatising people – whether they are overweight  people, smokers, poor people, those on welfare, or homeless people – improves neither health nor health equity.  But it does reinforce a discourse that ill health is the responsibility of individuals, rather than an outcome of unfair systems.

Of course, most of us do think about our own health at an individual and local level as well as at the social level.  There is a duty on charities and other public health bodies to inform the public about risks, as well as to advocate for social action on the causes of ill health.  The case of CRUK and the obesity posters illustrates a key dilemma: how to do this, without simply reinforcing the power imbalances that already hold those with least power, who are most vulnerable to the health risks of inequality, as somehow responsible for their own health?

As sociologist Oli Williams notes, sociologists have a reputation for critiquing the efforts of others in this regard, whilst offering few solutions; we “can and do sometimes come across as being problem rich but solution poor”.  But obesity is one field in which there is a rich tradition of social research that CRUK could, and perhaps should, have drawn on to inform a less damaging campaign. Williams’ own work would have been an excellent starting point: his exploration of how the stigma of bodyweight ‘gets under the skin’, and the resulting comic The Weight of Expectation, calls for support not stigma as the basis for care and health promotion.  Sociologists have a rich tradition of informing supportive not stigmatising interventions: examples include Football Fans in Training, an intervention developed by Kate Hunt, Sally Wyke and others to harness the appeal of premier league football to include men in a lifestyle intervention which successfully achieved weight loss.

Sociologists have also pointed to the need to refocus health promotion away from a narrow focus on body weight, and for interventions to address a broader, more holistic conception of health that better resonates with many in the population.  Warbrick and colleagues, for instance, discuss the ways in which Māori populations in Aotearoa/New Zealand are damaged by a focus on weight as if it is a (and often the) cause of their ill health.  They share vignettes on health-damaging effects of many weight loss programmes, given the individualistic approaches on offer, and the distress from ‘failure’ when participation does not lead to the only measure which counts: lower weight.   Eschewing any simplistic incorporation of a ‘Māori’ perspective from sanitised bicultural health approaches, they instead look to a perspective on Māori health that goes beyond a ‘targeted population’ and instead seeks solutions in the ‘more than human’ health worldviews, reconnecting people, environments, genealogy and history.

Innovative and productive practices are also the focus of Else Vogel and Annemarie Mol’s work with health professionals. They  start by noting the limited successes to date of many public health interventions that address eating as if it were a behaviour, undertaken within an obesogenic environment: they  “admonish us to behave, that is, to take control over what we eat and abstain from excessive food pleasures”.  Vogel and Mol look in detail at alternative practices of professional care, which focus not on control (which is counterproductive), but on feeling ‘need’ and cultivating ‘pleasure’: both bodily sensations that are not ‘natural’, but which require learning and training, as do the craft skills of providing edible food. The therapists they study address how their clients change from asking “am I being good?” to asking “is this good for me?”.

As Vogel and Mol note, even with practitioners who creatively support not shame, these individual programmes can do little about social determinants such as inadequate access to healthy food, or the erosion of public services, or children living in poverty, or grossly unequal incomes.  CRUK have resources far in excess of those available to individual practitioners.  Whist their aim of leveraging action at a government level can be applauded, it is a shame that their approach has inadvertently reinforced an overly behavioural, victim blaming approach.